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Introduction

Breathing Pattern Disorders (BPD) (or Dysfunctional Breathing) are abnormal respiratory patterns in relation to over-breathing which ranges from simple upper chest breathing to, at the extreme end of the scale, hyperventilation. Dysfunctional breathing (DB) is defined as chronic or recurrent changes in breathing pattern that cannot be attributed to a specific medical diagnosis, causing respiratory and non-respiratory complaints. [1]This is not a disease process, simply alterations in breathing patterns that interfere with normal respiratory processes. They can however, co-exist with disease such as COPD or heart disease, and in some cases can mimic cardiac symptoms[2][3].

BPDs are whole person problems, especially in long term conditions where dysfunctional breathing can destabilise mind and muscles, mood and metabolism[4]. They can play a part in, for instance, premenstrual syndrome[5], chronic fatigue[6], neck, back and pelvic pain[7][8], fibromyalgia[9][10]and some aspects of anxiety and depression.[1][11]

Clinically Relevant Anatomy

The Human respiratory system is located in the thorax. The thoracic wall consists of skeletal and muscular components, extending between 1st rib superiorly and rib 12th, the costal margin and the xiphoid process inferiorly[12]. The respiratory system can be classified in terms of function and its anatomy. Functionally, it is divided into two zones. The conducting zone, extend from the nose to the bronchioles, serves as a pathway for conduction of inhaled gases while the respiratory zone, is the site for gaseous exchange. It comprises of alveolar duct, alveolar sac and alveoli. Anatomically, it is divided into upper and lower respiratory tract. The upper respiratory tract starts proximally from the nose and ends at the larynx while the lower respiratory tract continue from the trachea to the alveoli distally.[13]

Epidemiology

It is often reported that around 10% of patients in a population are diagnosed hyperventilation syndrome[14]. However, far more people have a more subtle, yet likely clinically significant, breathing pattern disorder. Dysfunctional breathing is more prevalent in women (14%) than in men (2%)[14]

Little is known about dysfunctional breathing in children. Preliminary data suggest 5.3% or more of children with asthma have dysfunctional breathing and that, unlike in adults, it is associated with poorer asthma control. It is not known what proportion of the general pediatric population is affected.[15]

Etiology

Breathing pattern disorders occur when ventilation exceeds metabolic demands, resulting in symptom-producing hemodynamic and chemical changes. Habitual failure to fully exhale - involving an upper chest breathing pattern - may lead to hypocapnia. This involves a deficiency of carbon dioxide in the blood resulting from a breathing pattern disorder, the extreme of which involves hyperventilation. The result is respiratory alkalosis, and eventually hypoxia, or the reduction of oxygen delivery to tissue.[16][17]

As well as having a marked effect on the biochemistry of the body BPD can influence emotions[18], circulation, digestive function as well as musculoskeletal structures involved in the respiratory process. Essentially a sympathetic state and a subtle, yet a fairly constant state of fight-or-flight becomes prevalent. This can lead to changes in anxiety, blood pH, muscle tone, pain threshold, and many central and peripheral nervous system symptoms. So, despite not being a disease, BPDs are capable of producing symptoms that mimic pathological processes. For example, overuse of accessory breathing muscles can lead to neck and shoulder pain/dysfunction. Some even mimic cardiac and gastrointestinal problems.

Diagnostic Procedures

Nijmegan Questionnaire

High scores on the Nijmegan questionnaire have been shown to be both sensitive and specific for detecting people with tendencies consistent with breathing pattern disorders. The sensitivity of the Nijmegen Questionnaire in relation to the clinical diagnosis was 91% and the specificity 95%[20]

Assessment of breathing patterns

Breath Holding – People can normally hold their breath between 25 and 30 seconds. If less than 15 seconds may mean low tolerance to carbon dioxide.

Manual Assessment of Respiratory Motion (MARM) - Assess and quantify breathing pattern, in particular the distribution of breathing motion between the upper and lower parts of the rib cage and abdomen under various conditions. It is a manual technique that once acquired is practical, quick and inexpensive.[21]

Outcome Measures

Management / Interventions

Management commonly requires the removal of causative factors and the rehabilitation of habitual acquired dysfunctional breathing patterns. In order to achieve this most efficiently it may be necessary to restore normal function of the respiratory system such as thoracic mobility and muscle tone and length.

Manual Therapy Techniques

Based on your assessment, there are several manual therapy techniques that can be performed to treat muscles that have increased tone or activity, elevated and depressed ribs and alterations in mobility of thoracic articulations. These techniques include muscle energy techniques (MET), positional release, trigger point release and integrated neuromuscular inhibition techniques[19].

Breathing Retraining

Awareness of faulty breathing patterns

Relaxation of the jaw, upper chest, shoulders and accessory muscles

Abdominal/low-chest nose breathing pattern re-education

Awareness of normal breathing rates and rhythms, both at rest, during speech and activity.

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